Reexamination Verification Checklist

ALL adult household members MUST attend this interview Due to limited space, please do not bring minors to this appointment

Bring applicable items listed below, for ALL household members with you to your appointment Please be sure documents are current (dated within the last 60 days).

Completed/Signed (by all adults) Application enclosed with this notice: Do NOT use white out or other correction fluid Use BLUE or Black INK only - No pencil Do NOT leave any area blank - If you do not receive or own the item in question answer 'NONE' or 'No'— Do Not

use 'N/A'

Verification of Income include, but not limited to: Two (2) Current, consecutive paystubs or Current W-2 (s) Name, address, phone number to your employer TANF/Cash Benefits verification letter Unemployment Benefits - benefit letter or printout Workman's compensation - statement from Division of Workers compensation Alimony and child support pay history printout and court documents Veterans Administration - Benefit Verification letter Contributions - Signed letter from contributor including full address and phone number Self-employment —current ledgers, receipts, proof of expenses, recent tax return, current W-2 (s)

Family Composition include, but not limited to: Picture ID - ALL Adult members Birth Certificate and social security cards for all NEW family members Divorce Decree Adoption/Foster Care/ Relative Care papers Full-time student Verification (18 years or older)

Verification of Assets include, but not limited to: Checking/Savings account statements Certificate of Deposit (CD) account statement Stocks, Bonds, Mutual Funds or 401-K Owned property (Title or closing statement)

Verification of Allowances include, but not limited to: Day care - Signed Letter from provider including Name, address, and phone number, children cared for, amount

& frequency of payments Medical expenses - statement of payments Unreimbursed prescription medicine receipts (printout covering at least 12 full months)

Families in the Home Ownership Program (HOP) Mortgage and Escrow Statements Current Utilities Statements Home Association or Condo Assessment Fee, if applicable. Proof of Homeowner Insurance Proof of Flood Insurance, if applicable

Families that are participating in the Family Self-Sufficiency Program (FSS) Individual Training and Service Plan (ITSP)

Names addresses, phone numbers for: Two (2) person preferably relatives who can be contacted by this agency in an Emergency.

“If you or anyone in your family is a person with disabilities, and you require a specific accommodation in order to fully utilize our programs and services, please contact the housing authority.”

PERSONAL DECLARATION

NAME: (Last) (First) (Middle Initial)

HOME PHONE:

CURRENT ADDRESS:

WORK PHONE:

CITY, STATE, ZIP: CELL PHONE:

MAILING ADDRESS:

EMAIL ADDRESS:

EMERGENCY CONTACTS: Please list two individuals we may contact if you are not available:

Name: Name:

Telephone: Telephone:

Relationship: Relationship:

Note: For “Relation”, please provide if you are the head of household’s spouse, domestic partner, co-head, son, daughter, foster child/adult, live in aide or other adult. Also, please use one of the following to designate your “Race”: Black/African American, American Indian/Alaska Native, Asian, Native Hawaiian/Other Pacific Islander or White.

1. Head of Household Last Name First Name MI Date of Birth Sex (M/F) Relation

HEAD

Disability Yes No

U.S. Citizen Yes No

Full-time Student Yes No

Race Hispanic/Latino Yes No

Social Security Number Alien Registration Number

Is English your native language? Yes No

What is the primary language that you speak, read, and write? Do you need an interpreter? Yes No

If member is under 18, or over 18 and is a full-time student, list school name and address:

2. Household Member Last Name First Name MI Date of Birth Sex (M/F) Relation

Disability Yes No

U.S. Citizen Yes No

Full-time Student Yes No

Race Hispanic/Latino Yes No

Social Security Number Alien Registration Number

Is English your native language? Yes No

What is the primary language that you speak, read, and write? Do you need an interpreter? Yes No

If member is under 18, or over 18 and is a full-time student, list school name and address:

“If you or anyone in your family is a person with disabilities, and you require a specific accommodation in order to fully utilize our programs and services, please contact the housing authority.”

Personal Declaration Page 1 of 6

I. FAMILY COMPOSITION: List head of household first followed by the names of ALL persons who will live in the unit during the next 12 months where this will be their primary residence.

Page 2 of 6 Personal Declaration

3. Household Member Last Name First Name MI Date of Birth Sex (M/F) Relation

Disability Yes No

U.S. Citizen Yes No

Full-time Student Yes No

Race Hispanic/Latino Yes No

Social Security Number Alien Registration Number

Is English your native language? Yes No

What is the primary language that you speak, read, and write? Do you need an interpreter? Yes No

If member is under 18, or over 18 and is a full-time student, list school name and address:

4. Household Member Last Name First Name MI Date of Birth Sex (M/F) Relation

Disability Yes No

U.S. Citizen Yes No

Full-time Student Yes No

Race Hispanic/Latino Yes No

Social Security Number Alien Registration Number

Is English your native language? Yes No

What is the primary language that you speak, read, and write? Do you need an interpreter? Yes No

If member is under 18, or over 18 and is a full-time student, list school name and address:

5. Household Member Last Name First Name MI Date of Birth Sex (M/F) Relation

Disability Yes No

U.S. Citizen Yes No

Full-time Student Yes No

Race Hispanic/Latino Yes No

Social Security Number Alien Registration Number

Is English your native language? Yes No

What is the primary language that you speak, read, and write? Do you need an interpreter? Yes No

If member is under 18, or over 18 and is a full-time student, list school name and address:

6. Household Member Last Name First Name MI Date of Birth Sex (M/F) Relation

Disability Yes No

U.S. Citizen Yes No

Full-time Student Yes No

Race Hispanic/Latino Yes No

Social Security Number Alien Registration Number

Is English your native language? Yes No

What is the primary language that you speak, read, and write? Do you need an interpreter? Yes No

If member is under 18, or over 18 and is a full-time student, list school name and address:

7. Household Member Last Name First Name MI Date of Birth Sex (M/F) Relation

Disability Yes No

U.S. Citizen Yes No

Full-time Student Yes No

Race Hispanic/Latino Yes No

Social Security Number Alien Registration Number

Is English your native language? Yes No

What is the primary language that you speak, read, and write? Do you need an interpreter? Yes No

If member is under 18, or over 18 and is a full-time student, list school name and address:

Please use the back of this form to provide additional household member information.

Page 3 of 6 Personal Declaration

ADDITIONAL HOUSEHOLD INFORMATION A. Indicate if any of the adult household members have ever used a different first or last name(s):

Current Name: Previous Name:

B. Do you have a child under the age of six who has an elevated blood lead level? Yes No If yes, please make sure to bring the test results to your appointment.

C. Has your family composition changed since your last re-examination? Yes No

D. Do you currently have any children who are temporarily placed out of your home? Yes No

If yes, list the name of the child(ren):

E. Do you have temporary custody of or are you a foster parent to any household member 17 years of age or younger? Yes No If yes, list the name(s) of the household member(s):

F. Do you require a reasonable accommodation? Yes No

G. Has any household member(s) engaged in criminal activity within the last five years? Yes No If yes, please indicate the name of the family member(s):

1. EARNED INCOME – Includes employment and wages of any kind (full-time, part-time, seasonal, self- employment, temporary employment, cash payment).

Do you or any household member receive any earned income? YES NO

Verification – Provide two (2) consecutive paystubs, a payroll print-out/summary, or employer letter (preferably on letterhead); for self-employment, provide a copy of your most recent tax return (e.g. 1040, 1040A)

Household Member Name Employer/Source Information Amount Frequency*

Name: Phone:

Fax:

Address:

Name: Phone:

Fax:

Address:

Name: Phone:

Fax:

Address:

II. Household Income – Family Obligation – The U.S. Department of Housing and Urban Development (HUD) allows HACFL access to its Enterprise Income Verification (EIV) System, which provides HACFL with income data for all household members, whether you report it here or not. If you fail to report all household income, you may lose your voucher.

Page 4 of 6 Personal Declaration

Household Member Name Employer/Source Information Amount Frequency*

Name: Phone:

Fax:

Address:

Name: Phone:

Fax:

Address:

2. BENEFIT INCOME – Does any household member receive:

a. Disability/Worker’s Compensation? YES NO c. Food Stamps/Welfare? YES NO

b. Social Security or SSI? YES NO d. Unemployment? YES NO

Verification – Provide an award letter or printout with current benefit amount.

Household Member Name Income Type Amount ($) Frequency*

3. OTHER INCOME – Does any household member receive:

a. Alimony/Child Support? YES NO d. Foster Care/Adoption Assistance? YES NO

Case #:

b. Cash or help paying bills from friends or

family? YES NO e. Other Income? YES NO

c. Pension/Retirement? YES NO

Verification – Provide a statement/award letter/printout to show how much you currently receive.

Household Member Name Source Source Address & Phone Number Amount ($) Frequency*

*Income Frequency

Key: (B) Bi-Weekly (W) Weekly (M) Monthly (S) Semi-Monthly

Page 5 of 6 Personal Declaration

Are the net assets for your household equal to or less than $5,000.00? YES NO

III. AssetsDo you or any household member have: If yes, provide the following documents as verification:

Checking YES NO Most current bank statement

Savings/Certificate of Deposit (CD) YES NO

Retirement Acct (for example, 401K, 403B) YES NO Statement/printout from bank that shows current balance, interest rate, and penalty for early withdrawal of funds

Life Insurance Policy YES NO Document that shows type of policy and cash value

Stocks or Bonds YES NO Statement that you receive from broker

Real Estate YES NO Documentation of the value of the real estate and income you receive from it

Other Assets YES NO Statement of the value and income you receive from asset

If you answered “Yes” to any of the above, please provide more information about the asset(s) below:

Household Member Name Assets Type Source Source Address Cash Value($) Interest Rate

Please circle “YES” or “NO” to the following questions. Have you disposed of, sold, or given away any assets for less than the Fair Market Value during the past two (2) years? YES NO

If yes, please complete the following: 1) Type of asset: 2) Date of disposal:

4) Market value when disposed: $3) Amount received: $

IV. Childcare ExpensesNOTE: Complete Section IV ONLY if there are children 12 years or younger in the household.In order to be counted as a deduction the childcare must allow an adult member of the household to work, go to school, or search for a job.

Do you have any childcare expenses that are not reimbursed by someone outside your household? YES NO

Verification – Provide a bill/statement from your childcare provider or a printout.

Provider Name, Address, & Phone Number Name(s) of Child(ren)

Name of Person enabled to attend work,

school, or job search

Activity Enabled

(work, school, job search)

Cost ($) Frequency

Page 6 of 6 Personal Declaration

V. Medical Expenses

NOTE: Complete Section V ONLY if the head of household, co-head, or spouse is disabled or at least 62 years Do you or any household member have any of the following medical expenses? Amount paid out of pocket ($) Frequency of Expense

Prescriptions YES NO Doctors bills/co-pays YES NO

Insurance premiums YES NO

Hospital bills YES NO

Other: _ YES NO Verification: Provide any printouts or receipts for the last 12 months that you have to support the amount of medical expenses you have on an annual basis.

Do you have any expenses for the care of a disabled household member that enables any member of the household to work (example: care attendant, auxiliary apparatus or service animal)?

Verification: Provide bills or printouts showing how much you pay and how frequently.

YES NO

Describe Expense Estimated Annual Amount ($) Who is enabled to work?

CRIMINAL BACKGROUND CONSENT I understand that the Housing Authority is authorized to obtain criminal arrest records from law enforcement agencies to assist them in screening applicants and family members to be admitted to or remain in the program. This authorization assists the housing authority in complying with HUD requirements to deny or terminate assistance to applicants or participants in the program who are engaging in or have engaged in violent criminal or drug related activities. These activities are defined by HUD located within the HUD Contract.

I/We certify the following: 1. Each household member 18 years and older has read and signed the Authorization for Release of Information/ Privacy Act Notice and

Addendum and understands that a) it gives HACFL access to government sources of income information such as HUD’s EIV and b) HACFL will use that information to calculate household income and rent.

2. I/We have read and signed the Statement of Family Obligations. 3. The information given to HACFL regarding household composition, criminal status, income, allowances and deductions is accurate and

complete to the best of my/our knowledge and belief. Any changes must be reported in writing to HACFL within ten days of change. 4. I/We understand that any family composition changes may result in a change in my/our household’s voucher size. 5. I/We understand that false statements or information are punishable under federal law and are grounds for termination of housing assistance.

Signature of Head of Household:

Signature ofSpouse/Co-Head:

Signature of Other Adult Member:

Date:

Date:

Date:

Signature of Other Adult Member: Date:

Housing Discrimination: HACFL and federal law prohibit housing discrimination based on race, color, religion, sex, national origin, age, familial status or disability. If you believe you have been denied housing based on any of those factors, you may call the Office of Fair Housing and Equal Opportunity at 1-800-669-9777.

Confidentially Statement: The information provided on this form is confidential and will not be disclosed to anyone except as permitted by the HCV Program family or applicable law.

Fraud and False Statements: Title 18, Section 1001 of the U.S. Code states that a person who knowingly and willingly makes false and fraudulent statements to any department or employee of the United States Government, HUD, a Public Housing Authority or a Property Owner may be subject to penalties that include fines and/or imprisonment.

VI. Disability Expenses NOTE: Complete Section VI ONLY if one or more household member is disabled

OBLIGATIONS OF THE PARTICIPANT:

Statement of the Family Obligations

1. Supplying Required Information within the Specified Timeframe: Failure to provide all information within the requiredtimeframe as indicated in any communications from the HACFL will result in waiver of issuance of the 30-day Notice of RentIncrease to both the client and the landlord.

a) The family must supply any information that HACFL or HUD determines is necessary in the administration ofthe program, including submission of required evidence of citizenship or eligible immigration status.“Information” includes any requested certification, release or other documentation.

b) The family must supply any information requested by HACFL or HUD for use in a regularly scheduled re-examination or interim re-examination of family income and composition in accordance with HUDrequirements. HACFL Policy-Families must attend regularly scheduled re-examination appointments unlessthe family is elderly and disabled and receives HACFL approval to complete the re-examination process viamail. Families are required to report all new income, assets, and expenses of any member of the household tothe HACFL within ten (10) days of the date of the new income takes effect. And on their Annual Recertificationwith the exception of zero income households, FSS and Homeownership participants. These families mustreport all changes in income with ten (10) business days of the change.

c) The family must disclose and verify social security numbers and must sign and submit consent forms forobtaining information.

d) Any information supplied by the family must be true and complete.

2. HQS Breach Caused by Family (not applicable to clients in the Homeownership Program): The family is responsible for anHQS breach caused by the family.

3. Allowing PHA Inspection: The family must allow HACFL to inspect the unit at reasonable times and after reasonable notice.

4. Violation of Lease (not applicable to clients in the Homeownership Program): The family may not commit any serious orrepeated violation of the lease.

5. Family Notice of Move or Lease Termination: The family must notify HACFL and the owner before the family moves out ofthe unit, or terminates the lease on notice to the owner (clients in the homeownership program must notify HACFL if theyplan to move out of the home).

6. Owner Eviction Notice: The family must promptly give HACFL a copy of any owner eviction notice (notice of default onmortgage securing debt on a home for clients in the homeownership program).

7. Use and Occupancy of Unit:

a) The family must use the assisted unit for residence by the family. The unit must be the family’s only residence.

b) The composition of the assisted family residing in the unit must be approved by HACFL. The family must inform HACFLof the birth, adoption or court-awarded custody of a child within 10 business days.

c) The family must request HACFL approval to add any other family member as an occupant of the unit. HACFL Policy-Families must request HACFL approval to add a new family member, live-in-aide, foster child, or foster adult. Thisincludes any person not on the lease who is expected to stay in the unit for more than thirty (30) consecutive days, orninety (90) cumulative days, within a twelve month period, and therefore no longer qualifies as a “guest”. Requestsmust be made in writing and approved by the HACFL prior to the individual moving in the unit.

d) The family must promptly notify HACFL within ten (10) business days if any family member no longer resides in the unit.

Page 1 of 4

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e) If HACFL has given approval, a foster child or a live-in aide may reside in the unit. The HACFL has the discretion toadopt reasonable policies concerning residence by a foster child or live-in aide, and defining when HACFL consentmay be given or denied.

f) Members of the household may engage in legal profit-making activities in the unit, but only if such activities areincidental to primary use of the unit for residence by members of the family.

g) The family must not sublease or sublet the unit.

h) The family must not assign the lease or transfer the unit.

8. Absence from Unit: The family must supply any information or certification requested by HACFL to verify that the family isliving in the unit, or relating to family absence from the unit, including any HACFL-requested information or certificationon the purposes of family absences. The family must cooperate with HACFL for this purpose. HACFL Policy-The familymust promptly notify HACFL of absence from the unit. Notice is required under this provision only when the all familymembers will be absent from the unit for an extended period. An extended period is defined as any period greater than30 calendar days. Written notice must be provided to the HACFL at the start of the extended absence.

9. Interest in Unit (not applicable to clients in the Homeownership Program): The family must not own or have any interestin the unit.

10. Fraud and other Program Violation: The members of the family must not commit fraud, bribery or any other corrupt orcriminal act in connection with the programs.

a) Crime by household members: The members of the household may not engage in drug-related criminal activity orviolent criminal activity or other criminal activity that threatens the health, safety or right to peaceful enjoyment ofother residents and persons residing in the immediate vicinity of the premises. HACFL Policy-The family must notifythe HACFL of the arrest of a household member within 10 days of the occurrence for violent or criminal activityagainst persons or property, or involving alcohol, gangs, drugs and/or weapons.

b) Alcohol abuse by household members: The members of the household must not abuse alcohol in a way thatthreatens the health, safety or right to peaceful enjoyment of other residents and persons residing in the immediatevicinity of the premises.

c) Other housing assistance: An assisted family, or members of the family, may not receive Section 8 tenant-basedassistance while receiving another housing subsidy, for the same unit or for a different unit, under any duplicative (asdetermined by HUD or in accordance with HUD requirements) federal, State or local housing assistance program.

GROUNDS FOR TERMINATION OF ASSISTANCE: 24 CFR § 982.552

PHA Denial or Termination of Assistance for Family:

1. Action or inaction by family.

a) PHA may deny assistance for an applicant or terminate assistance for a participant under the programs because of thefamily’s action or failure to act as described in this section or §982.553. The provisions of this section do not affect denialor termination of assistance for grounds other than action or failure to act by the family.

b) Denial of assistance for an applicant may include any or all of the following: denying listing on the PHA waiting list, denyingor withdrawing a voucher, refusing to enter into a HAP contract or approve a lease, and refusing to process or provideassistance under portability procedures.

c) Termination of assistance for a participant may include any or all of the following: refusing to enter into a HAP contract orapprove a lease, terminating housing assistance payments under an outstanding HAP contract, and refusing to process orprovide assistance under portability procedures.

d) This section does not limit or affect exercise of the PHA rights and remedies against the owner under the HAP contract,including termination, suspension or reduction of housing assistance payments, or termination of the HAP contract.

Page 3 of 4

2. Requirement to deny admission or terminate assistance.

a) For provisions on denial of admission and termination of assistance for illegal drug use, other criminal activity, and alcoholabuse that would threaten other residents, see §982.553.

b) The PHA must terminate program assistance for a family evicted from housing assisted under the program for seriousviolation of the lease.

c) The PHA must deny admission to the program for an applicant, or terminate program assistance for a participant, if anymember of the family fails to sign and submit consent forms for obtaining information in accordance with part 5, subparts Band F of this title.

d) The family must submit required evidence of citizenship or eligible immigration status. See part 5 of this title for astatement of circumstances in which the PHA must deny admission or terminate program assistance because a familymember does not establish citizenship or eligible immigration status, and the applicable informal hearing procedures.

e) The PHA must deny or terminate assistance if any family member fails to meet the eligibility requirements concerningindividuals enrolled at an institution of higher education as specified in 24 CFR 5.612.

3. Authority to deny admission or terminate assistance

a) Grounds for denial or termination of assistance. The PHA may at any time deny program assistance for an applicant, orterminate program assistance for a participant, for any of the following grounds:

I. If the family violates any family obligations under the program (see §982.551, §982.633). See §982.553 concerningdenial or termination of assistance for crime by family members.

II. If any member of the family has been evicted from federally assisted housing in the last five years;

III. If a PHA has ever terminated assistance under the program for any member of the family.

IV. If any member of the family has committed fraud, bribery, or any other corrupt or criminal act in connection withany Federal housing program (see also §982.553(a)(1));

V. If the family currently owes rent or other amounts to the PHA or to another PHA in connection with Section 8 orpublic housing assistance under the 1937 Act.

VI. If the family has not reimbursed any PHA for amounts paid to an owner under a HAP contract for rent, damages tothe unit, or other amounts owed by the family under the lease.

VII. If the family breaches an agreement with the PHA to pay amounts owed to a PHA, or amounts paid to an owner bya PHA. (The PHA, at its discretion, may offer a family the opportunity to enter an agreement to pay amounts owedto a PHA or amounts paid to an owner by a PHA. The PHA may prescribe the terms of the agreement.)

VIII. If a family participating in the FSS program fails to comply, without good cause, with the family’s FSS contract ofparticipation.

IX. If the family has engaged in or threatened abusive or violent behavior toward PHA personnel.

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X. If a welfare-to-work (WTW) family fails, willfully and persistently, to fulfill its obligations under the welfare-to-work voucher program.

XI. If the family has been engaged in criminal activity or alcohol abuse as described in §982.553.

XII. If the family is in the homeownership program and defaults on the mortgage. Exceptions to this policy shall bereviewed on a case by case basis, particularly as it relates to family loss of income.

4. Terminating assistance

a) Terminating assistance for drug criminals.

i. The PHA must establish standards that allow the PHA to terminate assistance for a family under the program if thePHA determines that:

(1) Any household member is currently engaged in any illegal use of a drug; or

(2) A pattern of illegal use of a drug by any household member interferes with the health, safety, or right topeaceful enjoyment of the premises by other residents.

ii. The PHA must immediately terminate assistance for a family under the program if the PHA determines that anymember of the household has ever been convicted of drug-related criminal activity for manufacture of productionof methamphetamine on the premises of federally assisted housing.

iii. The PHA must establish standards that allow the PHA to terminate assistance under the program for a family if thePHA determines that any family member has violated the family’s obligation under §982.551 not to engage in anydrug-related criminal activity.

b) Terminating assistance for other criminals. The PHA must establish standards that allow the PHA to terminate assistanceunder the program for a family if the PHA determines that any household member has violated the family’s obligationunder §982.551 not to engage in violent criminal activity.

c) Terminating assistance for alcohol abusers. The PHA must establish standards that allow termination of assistance for afamily if the PHA determines that a household member’s abuse or pattern of abuse of alcohol may threaten the health,safety, or right to peaceful enjoyment of the premises by other residents.

I have read and understand the Family Obligations and Grounds for Termination of Assistance.

Head of Household Date Other Adult Member Date

Other Adult Member Date Other Adult Member Date

“If you or anyone in your family is a person with disabilities, and you require a specific accommodation in order to fully utilize our programs and services, please contact the housing authority.”

HACFL-004 Statement of Family Obligations

Original is retained by the requesting organization. form HUD-9886 (07/14)ref. Handbooks 7420.7, 7420.8, & 7465.1

Authorization for the Release of Information/Privacy Act Noticeto the U.S. Department of Housing and Urban Development (HUD) OMB CONTROL NUMBER: 2501-0014

and the Housing Agency/Authority (HA) exp. 07/31/2017

Persons who apply for or receive assistance under the followingprograms are required to sign this consent form:

PHA-owned rental public housingTurnkey III Homeownership OpportunitiesMutual Help Homeownership OpportunitySection 23 and 19(c) leased housingSection 23 Housing Assistance PaymentsHA-owned rental Indian housingSection 8 Rental CertificateSection 8 Rental VoucherSection 8 Moderate Rehabilitation

Failure to Sign Consent Form: Your failure to sign the consentform may result in the denial of eligibility or termination ofassisted housing benefits, or both. Denial of eligibility or termi-nation of benefits is subject to the HA’s grievance procedures andSection 8 informal hearing procedures.

Sources of Information To Be ObtainedState Wage Information Collection Agencies. (This consent islimited to wages and unemployment compensation I have re-ceived during period(s) within the last 5 years when I havereceived assisted housing benefits.)

U.S. Social Security Administration (HUD only) (This consent islimited to the wage and self employment information and pay-ments of retirement income as referenced at Section 6103(l)(7)(A)of the Internal Revenue Code.)

U.S. Internal Revenue Service (HUD only) (This consent islimited to unearned income [i.e., interest and dividends].)

Information may also be obtained directly from: (a) current andformer employers concerning salary and wages and (b) financialinstitutions concerning unearned income (i.e., interest and divi-dends). I understand that income information obtained from thesesources will be used to verify information that I provide indetermining eligibility for assisted housing programs and the levelof benefits. Therefore, this consent form only authorizes releasedirectly from employers and financial institutions of informationregarding any period(s) within the last 5 years when I havereceived assisted housing benefits.

Authority: Section 904 of the Stewart B. McKinney HomelessAssistance Amendments Act of 1988, as amended by Section 903of the Housing and Community Development Act of 1992 andSection 3003 of the Omnibus Budget Reconciliation Act of 1993.This law is found at 42 U.S.C. 3544.

This law requires that you sign a consent form authorizing: (1)HUD and the Housing Agency/Authority (HA) to request verifi-cation of salary and wages from current or previous employers; (2)HUD and the HA to request wage and unemployment compensa-tion claim information from the state agency responsible forkeeping that information; (3) HUD to request certain tax returninformation from the U.S. Social Security Administration and theU.S. Internal Revenue Service. The law also requires independentverification of income information. Therefore, HUD or the HAmay request information from financial institutions to verify youreligibility and level of benefits.

Purpose: In signing this consent form, you are authorizing HUDand the above-named HA to request income information from thesources listed on the form. HUD and the HA need this informationto verify your household’s income, in order to ensure that you areeligible for assisted housing benefits and that these benefits are setat the correct level. HUD and the HA may participate in computermatching programs with these sources in order to verify youreligibility and level of benefits.

Uses of Information to be Obtained: HUD is required to protectthe income information it obtains in accordance with the PrivacyAct of 1974, 5 U.S.C. 552a. HUD may disclose information(other than tax return information) for certain routine uses, such asto other government agencies for law enforcement purposes, toFederal agencies for employment suitability purposes and to HAsfor the purpose of determining housing assistance. The HA is alsorequired to protect the income information it obtains in accordancewith any applicable State privacy law. HUD and HA employeesmay be subject to penalties for unauthorized disclosures or im-proper uses of the income information that is obtained based on theconsent form. Private owners may not request or receiveinformation authorized by this form.

Who Must Sign the Consent Form: Each member of yourhousehold who is 18 years of age or older must sign the consentform. Additional signatures must be obtained from new adultmembers joining the household or whenever members of thehousehold become 18 years of age.

PHA requesting release of information; (Cross out space if none) IHA requesting release of information: (Cross out space if none)(Full address, name of contact person, and date) (Full address, name of contact person, and date)

U.S. Department of Housingand Urban DevelopmentOffice of Public and Indian Housing

Original is retained by the requesting organization. form HUD-9886 (07/14)ref. Handbooks 7420.7, 7420.8, & 7465.1

Signatures:

_____________________________________________ ______________Head of Household Date

___________________________________________Social Security Number (if any) of Head of Household

__________________________________________________ _______________Spouse Date

__________________________________________________ _______________Other Family Member over age 18 Date

__________________________________________________ _______________Other Family Member over age 18 Date

Consent: I consent to allow HUD or the HA to request and obtain income information from the sources listed on this form forthe purpose of verifying my eligibility and level of benefits under HUD’s assisted housing programs. I understand that HAs thatreceive income information under this consent form cannot use it to deny, reduce or terminate assistance without firstindependently verifying what the amount was, whether I actually had access to the funds and when the funds were received. Inaddition, I must be given an opportunity to contest those determinations.

This consent form expires 15 months after signed.

__________________________________________________ ________________Other Family Member over age 18 Date

__________________________________________________ ________________Other Family Member over age 18 Date

__________________________________________________ ________________Other Family Member over age 18 Date

__________________________________________________ ________________Other Family Member over age 18 Date

Penalties for Misusing this Consent:

HUD, the HA and any owner (or any employee of HUD, the HA or the owner) may be subject to penalties for unauthorized disclosures or improper uses ofinformation collected based on the consent form.

Use of the information collected based on the form HUD 9886 is restricted to the purposes cited on the form HUD 9886. Any person who knowingly or willfullyrequests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not morethan $5,000.

Any applicant or participant affected by negligent disclosure of information may bring civil action for damages, and seek other relief, as may be appropriate, againstthe officer or employee of HUD, the HA or the owner responsible for the unauthorized disclosure or improper use.

Privacy Act Notice. Authority: The Department of Housing and Urban Development (HUD) is authorized to collect this informationby the U.S. Housing Act of 1937 (42 U.S.C. 1437 et. seq.), Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d), and by the FairHousing Act (42 U.S.C. 3601-19). The Housing and Community Development Act of 1987 (42 U.S.C. 3543) requires applicants andparticipants to submit the Social Security Number of each household member who is six years old or older. Purpose: Your income andother information are being collected by HUD to determine your eligibility, the appropriate bedroom size, and the amount your familywill pay toward rent and utilities. Other Uses: HUD uses your family income and other information to assist in managing and monitoringHUD-assisted housing programs, to protect the Government’s financial interest, and to verify the accuracy of the information you provide.This information may be released to appropriate Federal, State, and local agencies, when relevant, and to civil, criminal, or regulatoryinvestigators and prosecutors. However, the information will not be otherwise disclosed or released outside of HUD, except as permittedor required by law. Penalty: You must provide all of the information requested by the HA, including all Social Security Numbers you,and all other household members age six years and older, have and use. Giving the Social Security Numbers of all household memberssix years of age and older is mandatory, and not providing the Social Security Numbers will affect your eligibility. Failure to provideany of the requested information may result in a delay or rejection of your eligibility approval.

Organization requesting release of information (name, address, telephone & date) Housing Authority of the City of Fort Lauderdale 500 West Sunrise Boulevard Fort Lauderdale, FL 33311 (954) 556-4100 Fax (954) 556-4104

This form cannot be used to request a copy of tax return. Instead use IRS form 4506, Request of a copy of Tax Forms.

PURPOSE The Housing Authority of the City of Fort Lauderdale may use this authorization and the information obtained with it, to administer and enforce program rules and policies.

• Law Enforcement Agencies• Credit Bureaus• Employers, Past and Present• Landlords• Providers of:

AUTHORIZATION

• AlimonyI authorize the release of any information (including documentation and other materials) pertinent to eligibility for or participation under any of the following programs:

• Child Care• Child Support• Credit• Handicapped Assistance

• Low —income Rental Indian Housing

• Medical Care• Low-income Rental Public Housing

• Pensions/Annuities• Mutual Help Homeownership Opportunity Program

• Schools and Colleges• Rental Assistance Program (RAP)

• U.S. Social Security Administration• Rent Supplement

• U.S. Department of Veterans Affairs• Section 8 Housing Assistance Payments Program

• Utility Companies• Section 23 and 100 Leased Housing

• Welfare Agencies• Section 23 Housing Assistance Payments

COMPUTER MATCHING NOTICE & CONSENT• Section 202

I agree that a Public Housing Agency, Indian • Section 221(d)(3) Below Market Interest Rate

Housing Authority may conduct computer • Turnkey Ill Homeownership Opportunities Program

matching programs with other governmental agencies including Federal, State Tribal or Local agencies. The governmental agencies include: • U.S. Office of Personnel Management• U.S. Social Security Administration• U.S. Department of Defense• U.S. Postal Service• State Employment Security Agencies• State Welfare and Food Stamp AgenciesThe Match will be issued to verify informationsupplied by the family:

I authorize the above named organization to obtain information about me or my family that is pertinent to eligibility for or participation in assisted housing programs.

I authorize an Indian Housing Authority, or a Public Housing Agency to obtain information on wages or unemployment compensation from State Employment Securities Agencies.

INFORMATION COVERED INQUIRIES MAY BE MADE ABOUT:

CONDITIONS: I agree that photocopies of this authorization may

• Child Care Expenses

be used for purposes stated above. If I do not sign • Credit History

this authorization, I also understand that my • Criminal Activity

housing assistance may be denied or terminated. • Family Composition• Employment, Income, Pensions, and Assets• Federal, State, Tribal, or Local Benefits

Signature of Head of Household

• Handicapped Assistance Expenses• Identify and Martial Status• Medical Expenses

Print Name of Head of Household & Date:

• Social Security Numbers• Residences and Rental History

Signature of Spouse or Other Adult Household Member

Print Name of Spouse/Other Adult Household Member

• Banks and Other Financial Institutions• Courts

This consent form expires 15 months after signed.

INDIVIDUALS OR ORGANIZATION THAT MAY RELEASE INFORMATION Any individual or organization including any governmental organization may be asked to release information. For example, information may be requested from:

HACFL-003 HACFL Authorization for the Release of Information

HACFL-0000 Lead Release Form

Lead Release Form Name: ______________________________________________ Phone:________________________________________ Address: ____________________________________________ City: ________________ State: _____ Zip: ___________

1. How many children in the household are under the age of six (6)? _______________ (List all below)

Name of Child(ren) under age 6 (First & Last Name) Date of Birth Male or Female

Relationship to child (Parent, grandparent,

foster, aunt, guardian, etc.)

2. Are there any children under the age of six (6) in the household with an elevated blood lead level? Yes No

3. If yes to question #2, indicate how many children do? ______________________. Please indicate the child’s or children’s name and blood lead level below. (You are required to provide the HACFL with a copy of the blood test results.) Name of Child(ren) under age 6 with an Elevated Blood Lead Level (First &

Last Name) Blood Lead Level

I authorize the HACFL to obtain information on:

A. Blood lead level test results for all of my children under the age of six (6).

B. Any reports completed by the local health agencies concerning lead testing for a current, past unit or future unit.

Head of Household/Guardian: _________________________________________ Date: _____________________ (Signature)

THIS FORM DOES NOT GO TO THE AGENT/OWNER OR LANDLORD ---------------------------------------------------------------------------------------------------------------------------------------------------------------- (Office Use Only) Housing Specialist: _________________________________________ Date: _____________________ Specify: Participant Applicant